Just like you, I’m trying to make sense of the world around me. But there are no templates for the bridge that healthcare’s building for its future.

All we can do is listen to weak signals and amplify them.

Last week, CVS finally bought Aetna for $69 billion (must we say almost bought because a judge is still questioning them). I spoke to someone closely familiar with the deal. He called it “vertical stacking” – to expand what CVS customers can get – from drugs to MinuteClinic consultations to now insurance.

Market is rife with speculation that Amazon is going to be biggest company in healthcare (fancy signing up for Amazon Prime Health?).

After such buzz, do you think other insurances or pharmacies will stay quiet? In the M&A world, more begets more.

In fact, the entire healthcare industry is in an M&A frenzy. As of June 2018, healthcare was only third in line (#1 is Energy, #2 is Media) in terms of size of deals. See below.

Zooming in and out. From the forest to the trees

Healthcare is so big ($8.7 trillion by 2020) that it nurtures mini-industries within itself. Like the space I’m most familiar with: gastroenterology, a medical specialty in high demand.

Long time ago, gastroenterologists (GIs) ran smaller solo or group practices. Despite the myriad challenges of running a medical business, doctors enjoyed the independence that private practices offered.

But over the years, everything got too complicated. From insurance reimbursements to regulatory compliance to even patient behavior. It just became tougher to stand alone. (Younger physicians hardly go solo today. Most join groups or hospitals.)

Smaller groups became bigger. Demand for colonoscopies (the main procedure that GIs perform) fueled the growth of free-standing ambulatory surgery centers.

Hospitals sensed the opportunity. And began luring gastroenterologists to gain access to their patients and bring home revenues from GI procedures. Under the thumbs of hospital administration doctors lost their independence. It didn’t help that they were forced to use monolithic hospital EHRs.

Well, the market’s now shifting again.

Private equity companies are fueling consolidation of GI groups. By providing capital for recruiting other groups, buying new medical equipment, removing administrative burdens and inefficiencies, streamlining technology and so on. They are courting doctors by offering them independence in a way that hospitals can’t.

And the super groups? I learnt that the pipeline goes all the way to 1,000 GIs operating under a single entity.

Private equity (PE) companies refer to this as a “roll up” strategy. These roll ups will create a different kind of market dynamic that doesn’t exist today. A tailwind of ancillary opportunities (imaging, pathology labs, nutrition counseling, administrative consolidation, EHR and billing systems unification, analytics and so on).

There are approximately 12,000 GIs in the US today. Present consolidation trends indicate that these deals would cover at least half that number over the next few years. The rest might continue to operate like they do today – finding ways to not buckle under market pressure.

Depending on where they are in their career, gastroenterologists welcome this trend or are cynical about it. Older doctors see it as a way to capitalize on what they’ve built so far. Younger doctors see it as selling out too soon. And then there are doctors who are more entrepreneurial – they see it as a way to shape what’s to follow.

Gastroenterology offers an insightful window into other specialties such as dermatology (booming these days), orthopedics, ophthalmology and others.

Larger private equity companies will eventually want to combine super groups across specialties and regions. If that makes no sense, think “vertical stacking” that my friend said as a reason for the CVS and Aetna merger. Or even think of Kaiser Permanante – a non-profit with 22,000 doctors on staff – with a PE twist.

Welcome to the new world!

Where do we go from here?

Just the other day, a doctor reached out to us (after reading our monthly newsletter). Saying it’s confusing out there. He runs a solo private practice but owns a surgery center with other doctors.

He hates all these things that he’s had to do in order to stay in practice. Like EHRs and MACRA, he said. So he stopped doing those things. But worries that he can’t keep ignoring them forever. It’ll catch up with him and then it’ll be too late.

In the end, he wondered if he should find a way to merge with somebody. But then his operations weren’t so clean. Wouldn’t PE investors want a cleaner practice?

And so the conversation went.

The sooner you accept the new reality, the better positioned you’ll be to shape that reality. Before it begins to shape you.

Say we met 10 years ago during the early stages of our business. And you asked me this: would healthcare delivery be more complicated in the future?

I would’ve shaken my head animatedly and said “no, it would be simpler!”.

I would’ve shown you technology trends. And told you that healthcare transactions will indeed become more automated, much simpler. Repeatable administrative tasks would be tech-enabled, algorithm driven.

As a company, we started life in billing claims for doctors. Back then I was quite sure billing would be way less complicated in the future. Insurances and hospitals would make sure that happens.

In fact, I would often urge our people to learn and upgrade their skills faster because their jobs would disappear soon.

I was wrong. Actually, very wrong.

I would’ve never guessed any of these things that baffle me about our industry today.

Baffling thing #1: It would cost more for doctors to make the same money

We never used to spend so much time obtaining prior authorizations (PA) before doctors perform procedures. Now we do. On an average, doctors today spend 16.4 hours per week or 853 hours every year on prior authorizations. Average wait time of response is 1-2 days.

I recently visited a hospital that houses some of the world’s best doctors. They can’t handle the PA burden. Their gastroenterology division spends 30+ days on average. Imagine what that means for a patient who urgently needs a procedure.

While PAs represent a bulk of the burden, there are many costs that add up. What’s worse is doctors are left with no choice but to meet these expenses. If they don’t, they don’t get paid.

Baffling thing #2: Healthcare law would get more and more complicated

On Jan 1st, 2017, a new law to track physician performance went into first gear. It’s called Medicare Access and CHIP Reauthorization Act of 2015 (or simply MACRA).

MACRA adds to the long list of regulatory mandates that practices already need to comply with. The law is applicable to roughly 55 million clinicians. It’s 2,398 pages long. Check it out here.

MACRA measures are converted to a point-based system. Using points, doctors are compared to other doctors. A score is derived based on what they could’ve done vs what they did. That finally determines how much someone makes.

We find doctors struggling to interpret the law, leave alone moving in the direction of incorporating the mandates.

Baffling thing #3: Technology, intended to simplify life, would end up making doctors miserable

Technology in the form of poorly designed EHRs adds to the burden of practicing medicine today. Some doctors feel it hurts their relationship with their patients. Some quit medicine altogether unable to deal with the technology.

My company recently completed the third stage of our Meaningful Use certification (now bucketed under the MACRA law) for our own EHR. It took our team us 6 weeks plus. The first stage took us a week. The second possibly 2-3 weeks. It’s reflective of how complicated the qualifying criteria have become.

Mandates require that doctors use certified technology to document their cases. If they don’t, they’ll lose money in the future.

Baffling thing #4: Coding would be so complicated. Creating another avenue for insurances to delay payments

When ICD-10 arrived, clinical codes exploded to 155,000 from an earlier set of 17,000. Insurances have begun to demand greater specificity for codes that doctors submit.

For example, earlier you’d use 530.11 as ICD-9 code for Reflux esophagitis (a digestive disease). Under ICD-10, you have to get specific and code say K21.0 – Gastro-esophageal reflux disease without esophagitis.

Doctors aren’t used to documenting this way. So specifically. The result is more avenues for insurances to deny or delay claims.

Baffling thing #5: In a world of desperate medical need, many doctors would actually give up medicine

It’s called the “Drop Out Club” – a networking site where doctors counsel one another to leave medicine. Burnout. Lack of enthusiasm. Depression. Long work hours. Increasing burden of bureaucratic tasks.

To become a specialist doctor, you have to spend four years in medical school and nine more years to train under a specialty. Imagine the kind of frustration a doctor must face in order to give it all up.

Our long, messy path to the future

Of course, I’m excited about the future. As a business, we keep developing a service or product to address the problems that we see. We figured that’s the best way to move forward in healthcare. Be more useful by solving problems that our clients face.

But I worry about the kind of long, messy path we keep traversing as an industry. A path that only gets murkier.

If we met today and you asked me the same question. Would healthcare be more complicated in the future?

I’d still shake my head and say “no, it’ll be simpler!” I’ll point you to today’s technology trends in artificial intelligence and machine learning. Without question, healthcare delivery will be simpler and more automated.

If you haven’t noticed already the popularity of doctor-review sites is on the rise. Healthgrades has over 3 million listed providers. Another review site Vitals claims to collect over 1.4 billion data points on doctors.

A survey found 84% of patients use online reviews to evaluate physicians. 47% of them are willing to go out-of-network for a doctor with more favorable reviews.

Some doctors resist the trend. While some others take advantage of it.

Like Dr. M who seems to engage patients masterfully. Take a look.

Dr. M has over 5 pages of reviews of Vitals with an average rating of a stellar 4.8 on 5. Here’s a sample review.

If you took time to read the review, this patient’s problems aren’t “over” but s/he rated the doctor 5 stars.

Without question, Dr. M is a great doctor with sound clinical outcomes. Surely, patients must be treated compassionately. Possibly, the practice is also operationally efficient.

But there’s something more happening here. For patients to make the effort of going online and writing a review.

Making your best patients into powerful brand advocates

In today’s digital world, reviews have the power to significantly boost patient volume. Simply because patients trust other patients.

A high quality patient experience can instantly turn patients into powerful brand advocates.

The secret to making this work is this.

You ASK.

Yes it’s that simple. So obviously simple that I’m sure you wonder if there’s more to it.

But the reality is that it works.

Right after a patient receives great service and care, request a review. You’ll be surprised at the number of responses you’ll receive.

Getting patients to review you online. In 3 simple steps

Here’s everything you need to know.

1. Instruct your front-desk to capture the patient’s email address. Patients will be willing to share their email address if they know that they’ll be receiving their medical records digitally and securely.

2. Remind patients. At the end of the visit, remind patients that you’ll be sharing their medical records by email.

3. Use this email script when you share medical records. Setup your electronic health record (EHR) software to automatically send the following email when you share medical records.

The mindset of ASK

Most people (including patients) respond well to a request when asked. Here are 4 strategies that’ll help you and your staff get into the mindset of asking reviews.

1. Provide quality services, actually.

2. Even a few reviews matter. Start small

3. Don’t bribe patients. Feel clean

4. Make patient engagement a team effort.

The world of healthcare is changing. Transforming into a more customer-centric arena. Reviews play a crucial role in engaging patients online. With one review building over the other.

I’m sitting in the waiting area across the endoscopy room of a major hospital. Mindless talkshow TV runs in the background. Patients are waiting. Patiently. Looking up anxiously every now and then from their phones. Towards the reception desk.

It’s a scene I’ve experienced for years while working in healthcare. While waiting for doctors.

But there’s something different in the air now.

Patients like those around me will encounter a doctor who’s excited and enthusiastic. But some will meet another who’s dreading her career.

Healthcare is changing faster than ever before.

It’s just not about technology disruption. There are many forces at play. Change in patient and societal behavior. Challenging finances. Evolving policy. Dichotomy of unmet supply and unmet demand for care.

Why some thrive and some struggle to survive

The doctor I’m about to meet is in the thriving category. He and his colleagues are excited about creating a new field. In endoscopic surgery. Yes, it’s what you think it is. Surgery while inserting a tube into your gut. Complex. New. Innovative.

And just the other day, I was scheduled for a video chat with a group of doctors at another hospital. A couple of days prior to the call, I learnt that the hospital suddenly terminated their contract. It’s possible that they are being replaced by nurse practitioners to save money.

I come across doctors from both ends of the spectrum. Excited on one end. Depressed on the other. Some even leave medicine for good.

How does this happen?

Doctors start making real money only in their mid 30s. After accumulating significant student loans. At that point in their career, they either choose to join private practice or find a job at a hospital.

The problem of being employed

Earlier, more doctors were inclined to go solo by developing their own practice. Newer generations of doctors increasingly want the comfort of a regular pay check and life-style.

However, being employed doesn’t take away from the fact that doctors are fiercely independent. While they are taught to give instructions in residency, they end up taking instructions from hospital administration. On the number of clinical procedures they must perform, the number of patients they must see and so on.

Eventually, they are disillusioned with the system. Medicine’s not what they had signed up for. However, they are stuck because they need the money (think student loan, mortgage, car loan, kids’ college fund etc.).

The problem of private practice

When in private practice, doctors are overwhelmed by the many, many balls that they need to juggle. Often to stay in the same place. They need to worry about getting paid correctly from insurance companies. Hiring and training staff. Getting their clinical codes right. Credentialing themselves with insurance panels. Fighting denials. Guarding themselves from law suits and audits. Interpreting long-winded healthcare laws (like MACRA). Dealing with complex technology.

It’s a tough life to go it alone.

Forgetting to unlearn. And re-learn

Eventually, doctors find a certain area within a specialty where they can make a predictable income. For example, there was a time when cardiologists made money from imaging. Despite an environment of declining cardiology reimbursements, some doctors continue to rely on income from reading EKGs.

Imagine what would they do when technology like AliveCor becomes mainstream. People with heart conditions might wear a personal EKG band. Further, the company recently announced that their technology can accurately interpret atrial fibrillation.

There’s more. Through big data analysis, they can even recognize patterns for hyperkalemia (or higher potassium levels) from the spikes and troughs of EKGs.

It’s all changing too fast.

The entire healthcare industry is in for a massive disruption. The key to ride such a wave is to forget fast. Because if you hang on to the past, you’ll be run over.

Losing meaning and purpose

After working hard to become doctors, many lose their way. There are many challenges that the healthcare industry poses before a doctor gets to simply see her patient. In navigating those challenges, doctors figure out ways to survive. And in surviving, they sometimes forget why they became doctors in the first place.

The relationship with patients becomes a routine, near commercial transaction. Not laced with the purity they had imagined in college. They adapt to circumstances. Medicine becomes a vocation. Not intellectually stimulating or challenging. And they enter a long tunnel of career stagnation. Only to be shaken up rudely by industry changes. Sometimes it’s technology. Sometimes it’s financial. Sometimes it’s regulatory or legal.

*

The other day, I was catching up with a friend on the west coast. She’s not in healthcare. She works at a large company that hasn’t kept up with the many changes in their industry.

I asked, “The bay area seems desperate for talent in machine learning. Why not take up an online course and get up to speed?” She’s those brainy ones. This would be right up her alley.

“Oh, I don’t get time from family, work, and myself,” she said.

“Don’t mind me saying this…but what’ll you do if they start lay-offs?” I asked with concern.

“May be, I’ll take a break from everything and learn stuff. May be like machine learning.”

The Statewide Planning and Research Cooperative System (SPARCS) is a comprehensive all payer data reporting system established by the New York State Department Of Health (NYSDOH).

The system is designed to collect patient level details such as patient demographics, diagnoses and treatments and charges for hospital inpatient stays and outpatient (ambulatory surgery, emergency department, and outpatient services) visits.

Facilities in New York are required to report data to SPARCS monthly to demonstrate compliance and avoid penalties.

Current data submission process

Under the current submission process, facilities submit SPARCS compliance data in an electronic, computer readable x12 837R format unique to requirements of the New York State. The data is transmitted to Department of Health’s Health Commerce System (HCS), where it is analyzed and response files are generated.

Revised data submission process

With the goal of standardizing data, the New York State Department Of Health (NYSDOH) will be using x225 837R format going forward. This is essentially x12 837I (standard used for submitting institutional claims) format with additional segment for race/ethnicity and NTE segment to collect source of payment and cardiac data elements.

NYSDOH has also partnered with Optum Government Solutions, Inc. for redesigning the processing system required for SPARCS.

Key points to consider:

Legacy system lack the utility to export data in 837I format. Facilities will need to check if their system provides data in the compatible format. If not, find a way to convert data into SPARCS compliant format.

The redesign of processing system may pose challenges with respect to the interface of the portal and method of submission within the portal.

NYSDOH is targeting complete implementation of the new system within 12 months.

Testing phase of SPARCS data submission in the new system begins on January 23rd 2018. Facilities can begin submitting test data to get comfortable with the nuances of the new submission method.

New format is applicable for Q4 2017 submissions and facilities are required to have at least one accepted claim for each claim type by April 30, 2018.

NYSDOH also requires 95% of the facility’s Q4 2017 data to be submitted as per the new format by June 30, 2018 and 100% of the facility’s Q4 2017 data to be submitted by Sep 30, 2018.

*Timelines are representative of current plan and are subject to change.

We have been working with several clients and helping them comply with Meaningful Use, PQRS, ASCQR, SPARCS, HCRA and THCIC compliance programs. We have already developed technology to convert data into new SPARCS compliant format. Click here to get in touch and explore further.

Are you wondering what you need know for 2018? Don’t worry. We did too. Here are all the major healthcare industry trends by leading publications. All in one place so that you don’t have to spend time searching to stay on top of your game.